Cancer Treatment Reviews 76 (2019) 22–32

Contents lists available at ScienceDirect

Cancer Treatment Reviews

journal homepage: www.elsevier.com/locate/ctrv

Anti-Tumour Treatment

Immunotherapy of colorectal cancer: Challenges for therapeutic efficacy T

Davide Ciardiello, Pietro Paolo Vitiello, Claudia Cardone, Giulia Martini, Teresa Troiani,
⁎
Erika Martinelli, Fortunato Ciardiello
Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, Italy

A R T I C LE I N FO A B S T R A C T

Keywords: A better knowledge of the complex interactions between cancer cells and the immune system has led to novel
Colorectal cancer immunotherapy approaches. Treatment with selective anti-PD1, anti-PD-L1 and/or anti-CTLA-4 monoclonal
Consensus molecular subtypes antibodies (mAbs) has been a revolution in the therapeutic scenario of several cancer types, with the highest
Immunotherapy clinical efficacy in melanoma and in lung cancer. Colorectal cancer is one of the tumours in which im-
Immune checkpoint inhibitor
munotherapy has been shown less effective. Whereas in deficient mismatch repair (MMR) or in highly micro-
Immune response
satellite instable (MSI-H) metastatic colorectal cancer there is clear clinical evidence for a therapeutic role of
immune checkpoint inhibitors, the vast majority of patients with proficient MMR or with microsatellite stable
(MSS) tumours do not benefit from immunotherapy. Defining the molecular mechanisms for immunogenicity in
metastatic colorectal cancer is needed in order to develop predictive biomarkers and effective therapeutic
combination strategies. A major challenge will be to identify, among the heterogeneous spectrum of this disease,
those patients with specific tumour and tumour infiltrating stroma molecular and functional characteristics, that
could be effectively treated with immunotherapy. In this review, we discuss the role of immune response in the
context of metastatic colorectal cancer. We summarize the available clinical data with the use of anti PD-1/PD-
L1 mAbs as single agents or in combination with anti CTLA-4 mAbs in MSI-H patients. Finally, we address the
challenges and the potential strategies for rendering the more frequent microsatellite stable (MSS) tumours
“immune-competent” and, therefore, amenable for effective immunotherapy interventions.

Introduction (MSI-H) [3–21]. However, the use of immune checkpoint inhibitors has
demonstrated little or no clinical activity in the majority of patients
Colorectal cancer (CRC) is the third most commonly diagnosed with mCRC [22].
cancer and the second type in terms of mortality. Over 1.8 millions of In this review, we discuss the role of immune response in the con-
CRC cases and 881.000 CRC-related deaths were estimated to occur in text of mCRC. We summarize the available clinical data with the use of
2018 in the World [1]. Despite significant improvements in CRC anti PD-1/PD-L1 mAbs as single agents or in combination with anti
treatment, the prognosis of patients with metastatic CRC (mCRC) re- CTLA-4 mAb in MSI-H mCRC patients. Finally, we address the chal-
mains poor, with a median overall survival (OS) of approximately lenges and the potential strategies for rendering the more frequent
30 months [2]. For this reason, novel and more effective therapeutic microsatellite stable (MSS) mCRC tumours “immune-competent” and,
strategies are necessary for metastatic disease. therefore, amenable for effective immunotherapy interventions.
In the last few years, a better knowledge of the complex interactions
between cancer cells and the immune system has led to novel im- Evidence for immune competence in colorectal cancers with
munotherapy approaches. The development of immune checkpoint in- microsatellite instability
hibitors, such as anti-CTLA-4 monoclonal antibodies (mAbs) (ipili-
mumab, tremelimumab), anti-PD-1 mAbs (nivolumab, pembrolizumab) Microsatellites are short segments of DNA that consist of multiple
and anti-PD-L1 mAbs (atezolizumab, durvalumab, avelumab), has repetitions of one to ten nucleotide base pairs. During DNA synthesis by
dramatically changed the therapeutic scenario for several types of DNA polymerase, these sequences are frequently subjected to muta-
cancer, including melanoma, lung, head and neck, kidney, bladder, tions, like base insertions or deletions, thus leading to frameshift mu-
Merckel cell carcinoma and mCRC with high microsatellite instability tations. The mismatch-repair (MMR) system has a major function in

⁎
Corresponding author at: Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, Via S. Pansini 5, 80131 Napoli, Italy.
E-mail address: fortunato.ciardiello@unicampania.it (F. Ciardiello).

https://doi.org/10.1016/j.ctrv.2019.04.003
Received 17 March 2019; Received in revised form 12 April 2019; Accepted 15 April 2019
0305-7372/ © 2019 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
D. Ciardiello, et al. Cancer Treatment Reviews 76 (2019) 22–32

recognizing and correcting these errors in the microsatellite region, analysis, both PD-1 and PD-L1 high expression were independent fac-
thus preventing genomic alterations [23]. tors associated with better recurrence-free survival, but only in dMMR
The presence of microsatellite instability, determined by the defi- cases [46].
ciency of one MMR protein, has been found in approximately 15–20%
CRC, with some differences according to tumour stage [24,25]. In fact, Molecular classification of colorectal cancer: implications for
the prevalence of deficient mismatch repair (dMMR) is higher in Stage immune competence
II (20%) and Stage III (12%) as compared to Stage IV (4%) CRC
[25–27]. The majority of MSI-H CRC are sporadic tumours and are Colorectal cancer is a genetically heterogeneous disease in which
associated to the inactivation by methylation of MLH1 [28]. However, several and different molecular pathways could be involved in tumour
approximately 3% of dMMR CRC are related to the Lynch Syndrome initiation, growth and progression. According to a comprehensive re-
(LS), which is associated with germ line mutations in the genes involved evaluation and comparison of CRC molecular gene expression profiling
in MMR (MLH1, MSH2, MSH6 and PMS2) [29]. Interestingly, patients that has been obtained by the use of different platforms, a Consensus
with MSI-H CRC share a characteristic clinical-pathological profile such Molecular Subtype (CMS) classification has been developed, that is
as the more frequent association with female sex, older age, BRAF ac- based on both tumour as well as infiltrating stroma gene expression.
tivating mutations, peritoneal disease, the presence of mucin-rich and According to the CMS classification, four major groups can be identi-
signet ring cancer cells, right sided primary tumours, early stage and fied. CMS1 (MSI Immune, approximately 14% of cases) are hypermu-
poorly differentiated tumours, with an abundance of tumour infiltrating tated tumours, generally with MSI-H features, can harbour BRAF mu-
lymphocytes (TILs) and a Crohn-like lymphoid reaction [30,31]. tations and show a robust immune infiltration. CMS2 (Canonical,
Diagnosis of MSI status can be assessed by various methodologies, approximately 37% of cases) are tumours, which are characterized by
like real time polymerase chain reaction (PCR), immunohistochemistry the activation of the Wnt and Myc pathways. CMS3 (Metabolic, ap-
(IHC) and next generation sequencing (NGS), with a good level of proximately 13% of the cases) tumours have frequently KRAS muta-
concordance [32–35]. dMMR CRC is characterized by a high tumour tions and display a deregulation in cancer cell metabolic pathways.
mutational burden (TMB), as a consequence of a large number of tu- CMS4 (Mesenchymal, approximately 23% of the cases) tumours are
mour DNA damages, including deletions, insertions and frameshift characterized by transforming growth factor beta (TGFβ) pathway ac-
mutations during cancer cell replication. tivation, enhanced angiogenesis, stromal activation and inflammatory
Measurement of TMB in the primary tumour and/or in blood sam- infiltrate [47].
ples from melanoma or lung cancer patients treated with immune Interestingly, the four CRC CMSs are characterized by relevant
checkpoint inhibitors has been suggested as a potential biomarker of differences in tumour microenviroment (TME). CMS1 and CMS4 are
therapeutic efficacy [36,37]. However, these results are largely from “hot” tumours with an intense immune infiltration, whereas CMS2 and
retrospective analyses and are obtained with different NGS-based CMS3 are “cold” tumours and lack immune activation. Therefore, the
techniques. In fact, it is still under investigation, in these tumour types, CMS classification represents a useful model to define potential ther-
which is the most appropriate cut-off for defining high TMB for ther- apeutic options for activating host immune responses, taking in account
apeutic use. In this respect, the evaluation of TMB has been recently that different strategies are needed for “hot” and for “cold” CRCs. In this
reported in a retrospective, subgroup and hypothesis-generating ana- respect, CMS1 CRC has a diffuse immune infiltrate with CD8+ TILs and
lysis of tumour samples from CRC patients that received as first line CD68+ macrophages. However, the concomitant up-regulation of im-
treatment for metastatic disease a 5-FU-based chemotherapy doublet mune checkpoint molecules (CTLA-4, PD-1, PD-L1) may represent a
plus bevacizumab or cetuximab [38]. In the 35 patients with MSI-H major mechanism of immune evasion in these tumours [48]. Thus, the
tumours, the median TMB was 52 mutations/Mb, whereas in the 475 use of immune checkpoint inhibitors could reverse the immune
patients with MSS tumours, the median TMB was 6 mutations/Mb. blockade and could activate an effective antitumor immune response in
Authors defined high TMB cases those with 8 or more mutations/Mb. this CRC subtype. On the other hand, CMS4 tumours are characterized
According to this seledted cut-off, better OS could be observed in mCRC by a different immune infiltration pattern, in which T regulatory cells
patients with high TMB, regardless of the first line treatment [38]. (Treg), myeloid-derived suppressor cells (MDSCs), monocyte-derived
These data need to be validated in a prospective fashion in appro- cells and T helper 17 (TH17) cells play a major role [49]. This ‘inflamed’
priately designed studies in order to define the TMB cut-off for clinical subtype, that is generally found in the microenvironment of immune-
use and if high TMB could be confirmed as a positive prognostic marker tolerant malignancies, is characterized by marked up-regulation of
in mCRC. immunosuppressive factors, such as TGFβ and CXCL12, and high ex-
The presence of a high number of tumour-associated neoantigens pression of genes encoding for chemokines that attract myeloid cells,
could favour the identification of cancer cells by the host immune including C-C motif chemokine ligand 2 (CCL2), interleukin 23 (IL-23)
system [39–41]. In this respect, MSI-H CRC are correlated with an in- and IL-17 [50]. Therefore, the potential immune response in CMS4
creased infiltration of TILs, such as CD8+ cytotoxic lymphocytes, Th1 tumours is blocked by the activation in the stroma of several mechan-
activated cells that produces IFNγ, and CD45 RO+ T memory cells, isms that favour an inflammatory environment and that, therefore,
which are also correlated with a better survival as compared to MSS suppress the immune response against cancer cells. In this respect,
CRC [42–44]. Moreover, the results of the international validation of TGFβ and other functional activators of epithelial to mesenchymal
the consensus immunoscore for the classification of colon cancer have transition (EMT) and of angiogenesis may be major players for tumour
demonstrated that a high immunoscore, based on CD3+ and CD8+ T immune evasion. It has been recently demonstrated by using a mouse
cell densities within the tumour, as measured by IHC and quantified by genetic model of colon cancer development, that cancer progression
digital pathology, is an independent positive prognostic biomarker for and metastatic spreading is due to the key role of TGFβ activation in the
the risk of recurrence in Stage I-III CRC [45]. High immunoscores were tumour stroma that specifically inhibits the immune response [51]. In
observed in 45% of cases with MSI-H tumours (138/304) and only in this respect, a therapeutic strategy of combining selective TGFβ in-
21% of cases with MSS tumours (273/1275) [45]. hibitors with immune checkpoint inhibitors is able to re-activate a ro-
Further, a tissue microarray analysis of a series of CRC samples bust immune response in this mouse colon cancer model [51].
detected high tumour PD-L1 expression in 5% of cases (19/394) and In contrast to CMS1 and CMS4 tumours, in which high levels of
high tumour infiltrating lymphocytes PD-1 expression in 19% of cases immune infiltrates are observed, although with different functional
(76/392) [46]. dMMR tumours had significantly higher levels of PD-1 characteristics, CMS2 and CMS3 tumours lack immune activation and,
and PD-L1 as compared to proficient MMR (pMMR) tumours (18% vs therefore, could be defined as “ immune desert” cancers. Different
2% and 50% vs 13%, respectively; P < 0.001 for both). In multivariate mechanisms may be responsible for this phenomenon, including

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D. Ciardiello, et al. Cancer Treatment Reviews 76 (2019) 22–32

Fig. 1. Consensus molecular classification according to the immune phenotype. CMS1 and CMS4 show activation of the immune system, with different orientation.
On the other hand CMS2 and CMS3 are poorly immunogenic and display a little activation of the immune response. dMMR: deficient mismatch repair; Transforming
growth factor beta: TGFβ; TILs: tumour infiltrating lymphocytes; NK: natural killer; CXCR3/CCR5: Chemokine (C-X-C motif) receptor 3/C-C chemokine receptor type
5; IFNy: interferon gamma; MSDCs: myeloid suppressor derived cells; CCL2: chemokine (C-C motif) ligand 2; IL-17/IL-23: interleukin 17/interleukin 23; PD1:
programmed death protein 1, CTLA4: cytotoxic T-lymphocyte-associated protein 4, IDO1: Indoleamine-pyrrole 2,3-dioxygenase; MHC I: major histocompatibility
complex 1; HLA: human leukocyte antigens; CXCL12: Chemokine (C-X-C-motif) ligand 12.

specific oncogenic-driven cancer cell pathways, lack of major histo- response of 2.8 months. Twelve months PFS was 50.4%, while
compatibility complex (MHC) class 1 molecules, up-regulation of non- 12 months OS was 73.4%. Grade 3–4 TRAEs occurred in 20% of pa-
classical human leukocyte antigens (HLA), that all may concur to tients. These adverse events were mainly asthenia, diarrhoea and
cancer immune evasion [52]. For these reasons, novel therapeutic ap- pruritus. In a different cohort, 119 patients with pre-treated dMMR
proaches are clearly needed to render immunogenic these tumours and mCRC received as induction treatment the combination of nivolumab,
possibly offer effective immunotherapies to CRC patients whose tu- 3 mg/kg, plus the anti-CTLA-4 mAb ipilimumab, 1 mg/kg, every
mours are CMS2 or CMS3 (Fig. 1). 3 weeks, followed by nivolumab, 3 mg/kg, every 2 weeks as main-
tenance [11]. The combination of anti PD-1 and anti-CTLA-4 im-
munotherapy displayed an ORR of 55% and a disease control rate at
Clinical efficacy of immune checkpoint inhibitors in mCRC 12 weeks of 80%. Twelve month PFS rate was 71%, while 12 month OS
patients with microsatellite unstable tumours was 85%. Grade 3–4 TRAEs were reported in 32% of patients.
Recently, the promising preliminary results of the combination with
Several trials have evaluated the clinical activity of immune nivolumab, 3 mg/kg, every 2 weeks plus low-dose ipilimumab, 1 mg/
checkpoint inhibitors in dMMR mCRC. In the phase II clinical trial kg, every 6 weeks in an untreated patient population with MSI-H mCRC
KEYNOTE 016, 41 patients with pMMR and dMMR chemorefractory have been presented [53]. This study has enrolled 45 patients. The ORR
mCRC or with dMMR non-CRCs were treated with the anti-PD1 mAb was 60% (27/45), with 7% CRs (3/45). The 12 months PFS and OS rates
pembrolizumab at the dose of 10 mg/kg every 3 weeks [22]. In the were 77% and 83%, respectively. Grade 3–4 TRAEs occurred in 16% of
cohort of patients with dMMR mCRC (10/41), the overall response rate patients, with only 7% of patients that had to discontinue therapy for an
(ORR) was 40% (4/10), with durable clinical responses, whereas ORR adverse event. Based on these results, the USA Food and Drug Admin-
was 0% in pMMR mCRC (18/41). Moreover, a high number of somatic istration (FDA) has approved pembrolizumab, nivolumab, and nivo-
mutations were associated with longer progression free survival (PFS). lumab plus ipilimumab, for the treatment of MSH-I mCRC patients that
Pembrolizumab therapy was well tolerated: Grade 3–4 treatment re- have progressed after therapy with fluoropyrimidines plus irinotecan or
lated adverse events (TRAEs) occurred in 17% of patients. Updated oxaliplatin.
results of the KEYNOTE 016 trial which included data on 86 patients Several phase III clinical trials are currently on-going to evaluate the
with dMMR cancers, reported 52% ORR with 12% complete responses efficacy of anti-PD1, anti-PD L1 and CTLA-4 mAbs in dMMR mCRC
(CR) in the cohort of CRC patients. The 2-year progression free survival (Table 1). Keynote 177 (NCT02563002) is a phase III randomized trial,
rate was 59% and the 2-year overall survival rate was 72% [15]. which is comparing pembrolizumab versus a standard of care che-
In the CheckMate 142, a nonrandomised phase II clinical trial, a first motherapy as first line treatment in dMMR mCRC. Further, the COM-
cohort of 74 patients with chemorefractory dMMR mCRC were treated MITT trial (NCT02997228) is exploring the clinical efficacy of treat-
with the anti PD-1 mAb nivolumab as single agent at the dose of 3 mg/ ment with the anti-PD L1 mAb atezolizumb as single agent or in
kg, every 2 weeks [10]. The ORR was 31.1%. Disease control longer combination with FOLFOX plus bevacizumab, as compared to FOLFOX
than 12 weeks was achieved in 69% of patients, with median time to

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D. Ciardiello, et al. Cancer Treatment Reviews 76 (2019) 22–32

Table 1
Ongoing phase II/III clinical trials evaluating the use of immune-checkpoint inhibitors in microsatellite instable colorectal cancer.
Study name Agent Target Study population Primary endpoint Phase Recruitment status

ATOMIC FOLFOX/Atezolizumab PD-L1 Stage III MSH-I CRC DFS III Active, recruiting
NCT02912559 Vs
FOLFOX
POLEM trial (NCT02912559) Avelumab PD-L1 Stage III MSH-I, POLE mutant CRC DFS III Active, recruiting
Vs
Observation
After adjuvant chemotherapy
KEYNOTE-177 Pembrolizumab PD-1 First line MSH-I mCRC PFS III Active, recruitment completed
(NCT02563002) vs OS
Standard therapy
COMMIT Trial Atezolizumab PD-L1 First line MSH-I mCRC PFS III Active, recruiting
(NCT02997228) Vs
FOLFOX/Atezolizumab/Bevacizumab
Vs
FOLFOX/Bevacizumab
NCT02227667 Durvalumab PD-L1 Pretreated mCRC ORR II Active

MSH-I: High microsatellite instability; mCRC: Metastatic colorectal-cancer; DFS: Disease free survival; PFS: Progression free survival; OS: Overall survival; ORR:
Overall response rate.

plus bevacizumab as first line therapy of dMMR mCRC patients. Two heavily pre-treated patient populations. Nevertheless, this relevant
trials are currently assessing the use of immune therapy in the adjuvant clinical benefit is limited to only a small group of tumours, which re-
setting. The ATOMIC trial (NCT02912559) is investigating the combi- presents approximately 4% of mCRC [60,61]. In fact, therapy with anti-
nation of FOLFOX plus atezolizumab vs FOLFOX as adjuvant treatment PD1 mAbs has no efficacy in pMMR mCRC patients. Novel therapeutic
in Stage III MSH-I CRC; while the POLEM trial (NCT02912559) is ad- strategies to render these tumours immune-competent are urgently
dressing the role of avelumab as maintenance treatment after 5-FU needed.
based adjuvant chemotherapy for Stage III MSI-H or POLE mutant CRC. It has been shown that chemotherapy, molecular targeted therapies
and radiotherapy could cause immunogenic cell death (ICD) in cancer
Are POLE and POLD1 mutations predictive for immune cells. This may be due to the release of damage associated molecular
competence of colorectal cancer? patterns (DAMPs), which in turn are recognised by host dendritic cells
(DC), that are able to present these antigens to CD8+ cytotoxic lym-
DNA polymerase epsilon (POLE) and DNA polymerase delta phocytes and, therefore, to activate these cells against cancer cells
(POLD1) are two key enzymes involved in the process of DNA synthesis [62–65]. These observations have led to the hypothesis that combining
and repair, which guarantee the correct replication of the genome treatment with immune checkpoint inhibitors and other anticancer
during cell cycle [54]. Interestingly, exonuclease domain mutations in therapies could potentially overcome the primary resistance to im-
POLE or in POLD1 genes determine a specific alteration of the enzyme munotherapy of MSS CRC.
proof-reading activity, with a deficit in DNA repair; thus, leading to the
accumulation of a very high number of mutations, up to ten times The potential role of radiotherapy
higher than MSH-I CRC. This translates in an increased risk of devel-
oping several types of cancer, including endometrial, colorectal, gastric, The “abscopal effect” is a rare phenomenon described for the first
pancreatic, breast and brain tumours [55–57]. time in 1953. It consists of tumour regression in a site distant from the
POLE mutations have been found in approximately 1–2% in the field of irradiation [66]. This may be due to the reactivation of host
overall population of pMMR CRCs. However, the frequency of this immune response against cancer cells. In fact, radiotherapy (RT) can
mutation arises to 5–7% in tumours of patients aged less than 50 years. increase the expression of MHC class I on cell membrane, and, thus, can
This rare type of “ultra-mutated” tumour shares similar clinical-pa- improve antigen presentation by DC with a strong immune activation
thological features with dMMR CRC, such as high levels of TILs, up- and subsequent ICD [67,68]. Currently, a few data are available for
regulation of immune checkpoint molecules, increase in cytotoxic T cell understanding the role of the combination of immune checkpoint in-
markers and in effector cytokines, suggesting a potentially enhanced hibitors and RT for the treatment of CRC. One study has evaluated the
immunogenicity. Moreover, Stage II-III CRC patients harbouring POLE combination of AMP224, a PD-1 inhibitor, with stereotactic body ra-
mutations showed a reduced risk of recurrence after surgery as com- diation therapy (SBRT) directed to liver metastases in patients with
pared to pMMR POLE wild type CRC patients [57]. A few clinical data mCRC. The treatment was safe and feasible. However, no responses
are currently available regarding the potential activity of immune were observed [69]. Another trial investigated the clinical activity of
checkpoint inhibitors in mCRC patients whose tumours carry POLE/ pembrolizumab in combination with RT (cohort 1) or with local abla-
POLD1 mutations. Of note, durable clinical responses were reported tion (cohort 2) in a pre-treated population of mCRC patients. In the first
with the use of the anti PD-1 mAb pembrolizumab in a patient with cohort, one major response (ORR 9%, 1/11) was observed in a meta-
POLE mutated endometrial cancer and in a patient with POLE mutated static site distant from the irradiation field [70]. Currently, several
pMMR CRC [58,59]. Probably in the near future, based on these pro- clinical trials are on-going (Table 2).
mising findings, POLE mutations will be tested alongside MMR in order
to better define CRC patients that could benefit from immunotherapy. The role of chemotherapy and of molecular targeted agents

Is it possible to render MSS tumours immune-competent and In mCRC the combination of chemotherapy (5-fluorouracil, ir-
amenable for immunotherapy? inotecan, oxaliplatin) with molecular targeted agents that inhibit an-
giogenesis (bevacizumab, aflibercept, ramucirumab) or epidermal
The use of immune-checkpoint inhibitors in patients with dMMR growth factor receptor (EGFR), such as cetuximab and panitumumab
mCRC determines significant and durable clinical responses, even in (in RAS wild type tumours) represents currently the standard of care for

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Table 2
Principal clinical trial investigating the combination of immune checkpoint inhibitors and radiotherapy.
Study name Agent Target Study population Primary endpoint Phase Recruitment status

NCT03102047 Chemoradiation/Durvalumab PD-L1 Stages II-IV MSS CRC Median Neoadjuvant Rectal Score II Active, recruiting
NCT03104439 Nivolumab/Ipilimumab/Radiation PD-L1 MSS/MSH-I mCRC Disease control rate II Active, recruiting
CTLA-4
NCT03007407 Durvalumab/Tremelimumab/Radiotherapy PD-L1 MSS mCRC ORR II Active, recruiting
CTLA-4
NCT02888743 Durvalumab/Tremelimumab ± Radiotherapy PD-L1 Metastatic to liver ORR II Active, recruiting
CTLA-4 MSS CRC

MSS: Microsatellite stability; MSH-I: High microsatellite instability; ORR: Overall response rate.

the first two lines of treatment [71–75]. by DC, and, therefore, may favour the activation of T-cell mediated
Novel experimental evidence suggests that the anti-tumour activity immune response [89]. Furthermore, cetuximab stimulates NK-medi-
of chemotherapy is not only due to the direct cytotoxic effects on cancer ated cell antibody-dependent cellular cytotoxicity (ADCC) [93]. In a
cells but also potentially to the stimulation of the host immune response recent phase II clinical trial (AVETUX), 43 mCRC patients with all RAS
[76]. In fact, conventional chemotherapy can augment the im- and BRAF wild type tumours were treated with the anti-PD-L1 mAb
munogenicity of cancer cells by inducing immunogenic cell death and avelumab plus cetuximab and FOLFOX6, as first line of therapy. An
by blocking mechanisms of immune-tolerance [77]. In particular, interim analysis of the AVETUX study on 20 patients has reported a
myeloid-derived suppressor cells (MDSCs) can promote immune escape promising ORR of 75% (15/20) with DCR of 95% 19/20), and an ac-
by inhibiting the activation and proliferation of CD8+ lymphocytes. In ceptable tolerability profile [94]. Furthermore, rechallenge with anti-
preclinical models, 5-fluorouracil treatment determines the apoptosis of EGFR mAb treatment in mCRC patients, that have previously obtained a
MDSCs, favouring the production of IFNγ by CD8+ cells and, therefore, clinical response to anti-EGFR therapy in previous lines of treatment, is
increasing T-cell mediated anti-tumour response [78]. Oxaliplatin can a potentially effective strategy, as recently suggested by small size,
also induce ICD by leading to the release of high mobility box binding proof of concept studies [95,96]. In this respect, our research group is
protein-1 (HMGB-1) from cancer cells, which is recognised by the toll currently conducting a large, single arm, multicentre phase II clinical
like receptor 4 (TLR4) and activates T CD8+ cells [77,79]. study, which evaluates the combined treatment with cetuximab plus
Vascular endothelial growth factor (VEGF) plays a central role in avelumab in pretreated mCRC patients, that obtained a partial or a
physiologic angiogenesis and tissue and wound repair processes and is complete response with an anti-EGFR mAb-based chemotherapy in the
often up-regulated in numerous malignancies in which significantly first line of treatment. Overall survival (OS) is the primary endpoint of
contributes to tumour-induced neoangiogenesis [80]. Further, VEGF this study (CAVE Colon study, Eudract Number 2017-004392-32).
may be involved in regulating immune functions in the TME by several Table 3 summarizes the clinical trials that are currently on going to
mechanisms, such as by decreasing T-cell migration from lymph nodes evaluate the role of combination strategies with chemotherapy, mole-
to tumour sites; by up-regulating suppressive immune checkpoint mo- cular targeted agents and immune checkpoint inhibitors in mCRC.
lecules (PD-1, PD-L1, CTLA-4, LAG 3); by increasing MCSDs; by in-
hibiting DC maturation; by down-regulation of MHC I and, con-
The role of MEK inhibition in combination with immune checkpoint
sequentially, by reducing the activation of CD8+ cells [81–89]. In this
inhibitors
respect, a study has recently evaluated the clinical activity of the
combination of the anti-PD-L1 mAb atezolizumab with bevacizumab
MEK is a key signalling molecule in the MAPK signalling pathway.
(cohort A) or the same combination plus modified FOLFOX6 che-
In preclinical models, it has been suggested that MEK inhibition can
motherapy (cohort B) [90]. In cohort A, 14 chemo-refractory mCRC
lead to up-regulation of MHC I and can increase the infiltration of
patients, who had received at least two previous lines of chemotherapy,
CD8+ lymphocytes into tumours. Moreover, in an in vivo mouse model
were treated with atezolizumab; 20 mg/kg, plus bevacizumab, 15 mg/
the combination of PD-1 and MEK blockade has determined a more
kg, every 3 weeks. One patient achieved a partial response (ORR, 1/14,
effective inhibition of tumour growth as compared to single agent
7%) and 9 patients had stable disease as best clinical response. In cohort
treatments, indicating a potential synergistic effect [97,98].
B, 23 mCRC patients received as first line of treatment atezolizumab
In 2016, Bendell presented the initial results of a phase Ib clinical
800 mg, bevacizumab 10 mg/kg and modified FOLFOX6 every 2 weeks.
trial, that was evaluating the clinical activity of the combination of
The ORR was 52% (12/23) with a median PFS of 14.1 months and a
atezolizumab, 800 mg every 2 weeks, plus cobimetinib, 60 mg orally,
median duration of response of 11.4 months [91]. The treatment had an
once a day (21 day on/7 day off) in chemo-refractory mCRC patients
acceptable safety profile. Grade 3–4 TRAEs were observed in 67% pa-
[99]. Twenty-three patients were treated. The ORR was 17% (4/23).
tients. These preliminary results that suggest a potential synergistic
Interestingly, 3 patients with a major response had an MSS tumour,
activity of atezolizumab with chemotherapy plus bevacizumab need to
while in the fourth patient with major response the tumour micro-
be confirmed in appropriately sized, larger, randomized clinical trials.
satellite status was unknown. Updated results from an expansion cohort
On the other hand, MODUL is a multicentre, randomized clinical trial,
of 84 heavily pre-treated patients reported an ORR of 8% (7/84), with
in which the best strategy of maintenance treatment in mCRC following
durable responses (median duration of response 14.8 months) and
a first line induction therapy with FOLFOX plus bevacizumab is being
median OS of 10 months [100]. On the basis of these promising results,
investigated with different therapeutic options. Recently, the results of
the IMblaze370 (COTEZO) phase III randomized clinical trial was in-
the cohort of patients, that have been treated the addition of atezoli-
itiated. The study enrolled 363 chemo-refractory mCRC patients, that
zumab to standard treatment with fluoropyrimidine and bevacizumab
were randomized (2:1:1) to receive atezolizumab, 1200 mg plus cobi-
after chemotherapy plus bevacizumab have been presented [92]. Un-
metinib 60 mg (21 day on/7day off schedule); atezolizumb mono-
fortunately, no clinical advantage of this triplet maintenance treatment
therapy at the dose of 840 mg every 2 weeks or regorafenib at standard
as compared to fluoropyrimidine plus bevacizumab was reported.
dose as control, standard arm of treatment. Unfortunately, the Im-
Cetuximab is a IgG 1 chimeric mouse-human mAb that inhibits the
Blaze370 trial did not met its primary endpoint. The median OS was
EGFR. Preclinical data have demonstrated that in vitro cetuximab could
8.9 month with atezolizumab plus cobimetinib vs. 8.5 month with re-
activate the opsonisation and phagocytosis of human colon cancer cell
gorafenib monotherapy [hazard ratio (HR) 1.00, 95% CI: 0.73, 1.38

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D. Ciardiello, et al. Cancer Treatment Reviews 76 (2019) 22–32

Table 3
Selection of ongoing clinical trial investigating the combination of immunotherapy with chemotherapy and target agents.
Study name Agent Target Study population Primary Phase Recruitment status
endpoint

CheckMate9X8 (NCT03414983) FOLFOXBevacizumab/Nivolumab PD-1 First line CRC PFS II/III Active, recruiting
Vs (MMR not spciefied)
FOLFOX/Bevacizumab
MEDITREME (NCT03202758) FOLFOX/Durvalumab/Tremelimumab PD-1 First line CRC Safety Ib/II Active,recruiting
CTLA- 4 (MMR not spciefied)
ElevetiION:CRC 101 FOLFOX/Bevacizumab/PDR001 PD1 First line MSS DLT I Terminated
(NCT03176264) CRC ORR
AVETUX (NCT03174405) FOLFOX/Cetuximab/Avelumab PD-L1 First line CRC PFS II Active, recruitment
(MMR not spciefied) completed
BACCI (NCT02873195) Capecitabine Bevacizumab/Atezolizumab PD-L1 Pretreated metastatic CRC PFS II Active, recruitment
vs (MMR not spciefied) completed
Capecitabine/Bevacizumab
NCT02860546 TAS-102/Nivolumab PD-1 Pretreated metastatic MSS irORR II Completed
CRC
NCT03396926 Capecitabine/Bevacizumab/Pembrolizumab PD-1 Pretreated metastatic MSS ORR II Active, recruiting
CRC
NCT02848443 TAS 102/Oxaliplatin/Nivolumab ± Bevacizumab PD-1 Pretreated metastatic MSS Safety I Active, recruiting
CRC
CAVE Colon (Eudract 2017- Cetuximab/Avelumab PD-L1 Pretreated metastatic CRC OS II Active, recruiting
004392-32) (MMR not spciefied)

CRC: Colorectal-cancer; MMR: mismatch repair; PFS: Progression free survival; MSS: Microsatellite stability; DLT: Dose limiting toxicities; ORR: Overall response
rate; PFS: Progression free survival; irORR: Immune related overall response rate; OS: Overall survival.

(p = 0.987)]. Median OS was 7.1 month with atezolizumab mono- immunotherapy. Several studies have been done to develop cancer
therapy [(HR vs. regorafenib, 1.19 (95% CI: 0.83, 1.71)]. Moreover, vaccines for human CRC. However, little or no clinical efficacy has been
there were no differences in terms of PFS and ORR across the treatment observed so far [106].
arms [101]. DCs are able to process tumour-associated antigens (TAA), present
them on the cell surface, causing the activation of T-cell and leading a
The role of combined PD-1 and CEA CD3 TCB blockade cancer specific immune response. Dendritic cell vaccines can be ob-
tained by isolating DC (autologous DC, ADC) from the host, pulsing
Carcinoembryonic antigen (CEA) is a member of the im- them ex vivo with TAA, tumour lysate and then after activation, re-
munoglobulin supergene family. It is localized on the cell membrane of infusing them into the patient. The results of a phase II clinical trial,
enterocytes in the colonic mucosa. CEA is over-expressed in the ma- which was aimed to compare autologous tumour lysate DC plus best
jority of mCRC with levels of expression which could be up to 60 times supportive care versus best supportive care, in pre-treated mCRC pa-
higher than in normal cells [102,103]. tients, were recently published [107]. Despite the fact that ADCs gen-
CEA CD3 TCB (RG7802, RO6958688) is a T-cell bispecific antibody erated a tumour specific immune response, there was no clear benefit in
(CEA-TCB) that binds simultaneously CEA on tumour cells and CD3 on terms of PFS or OS for the experimental treatment as compared with the
T cells. Thanks to its 2:1 ratio design, with two domains that bind CEA control arm.
on tumour cells and one domain which recognizes CD3 on T cells, CEA- Peptide vaccines are based on combination of one or multiple an-
TCB can induce T cell migration, activation and proliferation in tumour tigenic epitopes derived from tumour-associated antigens with a vac-
sites with a potential significant anti-cancer activity [104]. Tabernero cine adjuvant. These peptides are recognized and processed by DCs,
has recently presented the first results of a phase I clinical trial evalu- stimulating a T-cell specific activation against cancer cells. A phase II
ating CEA-TCB as monotherapy or in combination with atezolizumab in study evaluated the combination of 5 peptides (RNF43, TOMM34,
patients with CEA positive metastatic tumours [105]. In the mono- KOC1, VEGFR1 and VEGFR2) with an oxaliplatin-based chemotherapy,
therapy cohort, 31 patients with chemo-refractory mCRC were treated as first line treatment for patients with mCRC, but failed to demonstrate
with CEA-TCB at doses of 60 mg or higher. Disease control rate was any clinical benefit [108].
45%, with two patients having a partial response (PR, 2/31, 6%) and OncoVAX is an active specific immunotherapy (ASI) that consists in
with 12 patients reporting as best response a stable disease (SD, 12/31, the administration to patients of autologous irradiated cancer cells,
39%). In the combination arm, 11 patients were treated at doses of which could combine with the Bacillus Calmette-Guerin (BCG), as im-
CEA-TCB between 80 and 160 mg that were shown to have a clinical mune-adjuvant. In a phase III study, 254 patients with stage II or III
activity. Interestingly, in this heavily pre-treated mCRC population, two resected colon cancer were randomized to receive ASI or not as ad-
patients had a partial response (PR, 2/11, 18%) and 7 a stable disease juvant treatment [109]. ASI consisted in 3 weekly vaccinations, starting
(SD, 7/11, 64%). CEA-TCB treatment displayed a complex safety pro- 28 days after surgery, with a fourth vaccination at 6 months with irra-
file. The most common grade 3 TRAEs, at doses of 40 mg or higher, diated tumour cells. Interestingly, for patients with stage II disease, it
were diarrhoea, infusion related reactions, pyrexia, with five patients in was observed a 61% reduction of the risk of the recurrence with ASI as
the single agent treatment arm that experienced a dose limiting toxicity compared to surgery alone with a trend toward improvement in OS.
(DLT) and two patients that experienced a DLT in the combination arm. Based on these results, a confirmatory, randomized phase III trial is now
Thus, the safety profile represents a major issue for the future devel- recruiting patients with stage II colorectal cancer to receive OncoVAX
opment of this drug. or observation after surgery (ACTIVE trial, NCT02448173).
Oncolytic viruses are genetically modified viruses that could be able
The role of cancer vaccines to selectively recognize and kill cancer cells; thus, avoiding damages to
the host normal tissues. In a preclinical model, AD881, an oncolytic
The activation of a selective host immune response against cancer adenovirus, was able in vitro to induce ICD in CT26 cancer cells [110].
cell antigens could be an effective strategy to boost specific Similarly, G207 (a multi-mutated herpes simplex virus type I) had a

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D. Ciardiello, et al. Cancer Treatment Reviews 76 (2019) 22–32

Table 4
Selection of ongoing trial investigating the combination of immunotherapic agents.
Study name Agent Target Study population Primary Phase Recruitment status
endpoint

NCT02448173 Surgery/OncoVAX OncoVAX Stage II CRC (MRR non specified) DFS III Active, recruiting
Vs
Surgery
NCT02981524 GVAX colon vaccine/Pembrolizumab PD-1 Pretreated metastatic MSS CRC ORR II Active, non recruiting
NCT02959437 Azacitidine/Epacadost/Pembrolizumab PD-1 Pretreated metastatic MSS CRC Safety I/II Active non recruiting
IDO ORR
NCT02559024 MEDI6469 OX-40 Liver metastasis of CRC Safety I Active, non recruiting
(MRR non specified) Immune score
NCT03241173 INCAGN01949, OX-40 Advanced solid tumour Safety I/II Active, non recruiting
INCAGN01949/Ipilimumab, INCAGN01949/ ORR
Ipilimumab,
NCT02777710 PEXIDARTINIB/Durvalumab CSF-1R Pretreted metastatic CRC (MRR non Safety I Active, non recruiting
PD-l1 specified) ORR
NCT02503774 Oleclumab ± Durvalumab CD73 Advanced solid tumour Safety I Active, recruiting
PD-L1
NCT03207867 PDR001/NIR178 A2AR Advanced solid tumour (including MSS ORR II Active, recruiting
PD-1 CRC)
NCT03549000 NZV930, A2AR Advanced solid tumour ORR I Active, recruiting
NZV930/PDR001, CD73
NZV930/NIR178, PD-1
NZV930/NIR178/PDR001

CRC: Colorectal-cancer; MMR: mismatch repair; DFS: Disease free survival; MSS: Microsatellite stability; ORR: Overall response rate.

significant cytotoxic activity in a panel of five human colon cancer cells cells, epithelial cells, endothelial cells and smooth muscle cells.
lines [111]. Despite these compelling preclinical results, to date limited Interactions between OX40 and OX40L stimulate proliferation, activa-
evidence is available in patients with mCRC. A phase I/II clinical trial tion and cytokine productions of CD4+ and CD8+ cells, the expansion
evaluated the safety and the anti-tumour activity of NV1020, a ge- of antigen-specific memory T cells and suppress the differentiation of
netically engineered oncolytic herpes simplex virus, in pre-treated T-reg cells [118]. Interestingly, it has been reported that high levels of
chemo-refractory mCRC patients with liver metastasis [112]. Among expression of OX40 in TILs were founds in 50% of tumours samples and
the twenty-two patients that received the optimal dose treatment, dis- were correlated with a increased overall survival [119].
ease control rate was 68% (1 partial response and 14 stable disease as An in vivo study using the Colon 26 cancer model showed that
best responses); median time to progression was 6.4 months and treatment with an OX40-agonist induced depletion of T-reg and induced
median OS was 11.8 months. tumour-regression [120]. Several phase I/II trials are investigating the
safety and activity of OX40 agonists as monotherapy or in combination
The role of IDO inhibitors with immune checkpoint inhibitors in different tumours including
mCRC (see Table 4).
Indolamine 2,3-dioxygenase (IDO) is an enzyme that catalyses the
conversion of tryptophan in kynurenine. Tryptophan is an essential The role of macrophage colony-stimulating factor 1 receptor (CSF1R)
amino acid for T-lymphocytes functions. Its depletion induces apoptosis inhibition
and prevents T cell activation. On the other hand, kynurenine can
promote Treg activation and has an immunosuppressive effect Myeloid-derived cell infiltration in TME could represent a me-
[113–115]. chanism of tolerance and immune escape. In fact, MSDSs can suppress
It was found that high IDO expression was present in nearly 40% of the maturation of DCs, inhibit the activation and proliferation of T-cells
CRC, it correlates with poor prognosis and with liver metastasis [116]. and contribute to invasiveness and metastasis [121].
In a mouse model of colon cancer, IDO inhibitions determined a mod- CSF1R is a receptor that is expressed on monocytoid cells. its acti-
ification in tumour microenvironment by reducing Treg and by in- vation by CSF favours the differentiation in MSDSs. In preclinical
creasing the levels of pro-inflammatory cytokines. However, IDO in- models of colon cancer, CSF1R inhibition suppressed MSDCs and de-
hibition alone was not able to induce tumour regression, indicating that layed tumour growth [122]. Thus, a phase I study with the combination
a combination treatment with immune checkpoint inhibitors could be a of a CSF1R inhibitor, pexidartinib, with an anti-PD-L1 antibody, dur-
better strategy. A few data are available on the use of IDO inhibitors in valumab, in patients including colorectal and pancreatic cancer, is now
a clinical setting in mCRC. A phase I study has assessed the tolerability under evaluation (NCT02777710).
of the IDO inhibitor epacadost in 52 patients with pre-treated solid
tumours, including 29 patients with mCRC [117]. Further, a phase I/II The role of CD73 inhibition
clinical trial evaluating the combination of epacadostat with pem-
brolizumab and the epigenetic agent azacitidine in patients with ad- High levels of adenosine in TME elicit the migration of cancer cells,
vanced non small cell lung cancer and MSS mCRC is currently on-going stimulate angiogenesis, activate stromal remodelling and determine an
(NCT02959437). immunosuppressive microenviroment. In fact, adenosine binds the
adenosine A2A receptor (A2AR) and inhibits proliferation and activa-
The role of OX40 agonists tion of cytotoxic lymphocytes. Moreover, adenosine promotes the in-
filtration of immunosuppressive cells, such as T-reg and MDSCs [123].
OX40 (CD134) is a member of the tumour necrosis factor family of The enzyme CD73 is expressed on cancer and immune cells and catalyse
receptors, which is expressed by activated T cell, and acts as a co-sti- the conversion of adenosine monophosphate to adenosine. Recently, it
mulatory molecule. Its ligand OX40L is exposed on the cell membrane has been shown in a mouse model that dual inhibitions of A2AR and
of antigen-presenting cells, such as Langerhans cells, mast cells, NK CD73 improve anti-cancer immune response [124]. To date, three

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D. Ciardiello, et al. Cancer Treatment Reviews 76 (2019) 22–32

clinical trial evaluating the feasibility and activity of immune check- [7] Wolchok JD, Chiarion-Sileni V, Gonzalez R, Rutkowski P, Grob J-J, Cowey CL,
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Nivolumab versus everolimus in advanced renal-cell carcinoma. N Engl J Med
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with advanced gastric or gastro-oesophageal junction cancer refractory to, or in-
Immunotherapy of cancer has become a novel effective therapeutic tolerant of, at least two previous chemotherapy regimens (ONO-4538-12,
ATTRACTION-2): a randomised, double-blind, placebo-controlled, phase 3 trial.
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cidated in activating host immune response. Treatment with selective [10] Overman MJ, McDermott R, Leach JL, Lonardi S, Lenz H-J, Morse MA, et al.
anti-PD1, anti-PD-L1 and/or anti-CTLA4 mAbs has been a revolution in Nivolumab in patients with metastatic DNA mismatch repair-deficient or micro-
satellite instability-high colorectal cancer (CheckMate 142): an open-label, mul-
the therapeutic scenario of several cancer types, with the highest clin-
ticentre, phase 2 study. Lancet Oncol 2017;18:1182–91. https://doi.org/10.1016/
ical efficacy so far in melanoma and in lung cancer. However, even for S1470-2045(17)30422-9.
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patients and that biomarker selection is needed for the optimization of Durable clinical benefit with nivolumab plus ipilimumab in DNA mismatch re-
pair–deficient/microsatellite instability-high metastatic colorectal cancer. J Clin
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Unfortunately, colorectal cancer is currently one of the tumour [12] Cohen EEW, Soulières D, Le Tourneau C, Dinis José, Licitra L, Ahn M-J, et al.
types in which immunotherapy has been shown less effective. Whereas Pembrolizumab versus methotrexate, docetaxel, or cetuximab for recurrent or
metastatic head-and-neck squamous cell carcinoma (KEYNOTE-040): a rando-
in dMMR or MSI-H mCRC there is clear clinical evidence for a ther- mised, open-label, phase 3 study. Lancet 2019;393:156–67. https://doi.org/10.
apeutic role of immune checkpoint inhibitors, the majority of mCRC 1016/S0140-6736(18)31999-8.
patients with pMMR or MSS tumours do not benefit from im- [13] Reck M, Rodríguez-Abreu D, Robinson AG, Hui R, Csőszi T, Fülöp A, et al.
Pembrolizumab versus chemotherapy for PD-L1–positive non–small-cell lung
munotherapy. Up to date, although promising preclinical findings and cancer. N Engl J Med 2016;375:1823–33. https://doi.org/10.1056/
preliminary clinical results, we do not yet have clear evidence for im- NEJMoa1606774.
munotherapy efficacy in these patients. [14] Bellmunt J, de Wit R, Vaughn DJ, Fradet Y, Lee J-L, Fong L, et al. Pembrolizumab
as second-line therapy for advanced urothelial carcinoma. N Engl J Med
A better knowledge of the molecular mechanisms that define the 2017;376:1015–26. https://doi.org/10.1056/NEJMoa1613683.
immune competence of a mCRC is needed in order to develop predictive [15] Le DT, Durham JN, Smith KN, Wang H, Bartlett BR, Aulakh LK, et al. Mismatch
biomarkers and effective therapeutic combination strategies such as repair deficiency predicts response of solid tumors to PD-1 blockade. Science (New
York, NY) 2017;357:409–13. https://doi.org/10.1126/science.aan6733.
with chemotherapies or with other molecular targeted agents or with
[16] Schmid P, Adams S, Rugo HS, Schneeweiss A, Barrios CH, Iwata H, et al.
co-stimulatory molecules. A major challenge will be in the next future Atezolizumab and nab-paclitaxel in advanced triple-negative breast cancer. N Engl
to identify, among the heterogeneous spectrum of mCRC, those patients J Med 2018;379:2108–21. https://doi.org/10.1056/NEJMoa1809615.
with specific tumour and tumour infiltrating stroma molecular and [17] Rittmeyer A, Barlesi F, Waterkamp D, Park K, Ciardiello F, von Pawel J, et al.
Atezolizumab versus docetaxel in patients with previously treated non-small-cell
functional characteristics, that could be effectively treated with im- lung cancer (OAK): a phase 3, open-label, multicentre randomised controlled trial.
munotherapy. Lancet 2017;389:255–65. https://doi.org/10.1016/S0140-6736(16)32517-X.
[18] Barlesi F, Vansteenkiste J, Spigel D, Ishii H, Garassino M, de Marinis F, et al.
Avelumab versus docetaxel in patients with platinum-treated advanced non-small-
Aknowledgements cell lung cancer (JAVELIN Lung 200): an open-label, randomised, phase 3 study.
Lancet Oncol 2018;19:1468–79. https://doi.org/10.1016/S1470-2045(18)
The laboratory of FC is funded by research grants from Associazione 30673-9.
[19] Choueiri TK, Larkin J, Oya M, Thistlethwaite F, Martignoni M, Nathan P, et al.
Italiana per la Ricerca sul Cancro (AIRC, IG n. 18972) and from Regione Preliminary results for avelumab plus axitinib as first-line therapy in patients with
Campania (Progetti per la Ricerca Oncologica, I-CURE grant). advanced clear-cell renal-cell carcinoma (JAVELIN Renal 100): an open-label,
dose-finding and dose-expansion, phase 1b trial. Lancet Oncol 2018;19:451–60.
https://doi.org/10.1016/S1470-2045(18)30107-4.
Conflict of interests
[20] D’Angelo SP, Russell J, Lebbé C, Chmielowski B, Gambichler T, Grob J-J, et al.
Efficacy and safety of first-line avelumab treatment in patients with stage IV me-
FC has participated to Advisory Boards for Merck KgA, Bayer, tastatic merkel cell carcinoma: a preplanned interim analysis of a clinical trial.
JAMA Oncol 2018;4:e180077. https://doi.org/10.1001/jamaoncol.2018.0077.
Amgen, Roche, Servier, Pfizer, and he has received institutional re-
[21] Antonia SJ, Villegas A, Daniel D, Vicente D, Murakami S, Hui R, et al. Durvalumab
search grants from Merck KgA, Bayer, Amgen, Roche, Ipsen. The other after chemoradiotherapy in stage III non–small-cell lung cancer. N Engl J Med
authors have no interests to disclose. 2017;377:1919–29. https://doi.org/10.1056/NEJMoa1709937.
[22] Le DT, Uram JN, Wang H, Bartlett BR, Kemberling H, Eyring AD, et al. PD-1
blockade in tumors with mismatch-repair deficiency. N Engl J Med
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